MentalHealthandPsychosocialSupportSituationalAssessmentNeeds,Services,andRecommendationsforSupporttoRefugees,AsylumSeekers,andMigrantsinGreece

February2016

1.GoalsTheprimary goals of thismental health andpsychosocial support (MHPSS) situational assessment1were asfollows:1)Toobtainanunderstandingofperceivedandidentifiedneedsamongrefugees,asylumseekers,andmigrantsinGreece;2)ToconductamappingofexistingMHPSSservicesacrossGreekislandsandinAthens;3)ToproviderecommendationsineffortsofstrengtheningtheMHPSSresponseinGreece.Forquestionsortolearnmoreaboutthisassessment,pleasecontact:Dr.InkaWeissbecker,IMCGlobalMentalHealthandPsychosocialAdvisor,iweissbecker@InternationalMedicalCorps.org2.MethodologyThe rapidMHPSS situational analysiswas conducted by IMC’sMental Health Coordinator inGreece, ClaireWhitney, from16December2015 - 20 February2016. Theassessment isbasedonadesk reviewofpolicydocumentsandassessmentreports,fieldresearchthatincludedamappingofMHPSSactorsandservices,andkeyinformantinterviewsthroughouttheGreekislandsofLesvos,Samos,Leros,andKos,andinAthens.Datacollection focused on assessing the availability and accessibility of existingmental health and psychosocialsupportservices,aswellasidentifyinganyestablishedcoordinationmechanismsandreferralpathways. 1Thisreportpresentsasnapshotofthesituationinarapidlychangingenvironment.Thereportreflectskeyinformantknowledge,perceptionsandexperienceatthetimeofdatacollection.Giventhatthesituationandservicesavailablearealwaysinflux,thereportmayhavegapsintermsofinformationregardingupdatestoneeds,services,actors,coordination,andreferralpathways.

Adeskreviewofrelevantassessmentreportsandpolicydocumentsincluded:• HumanitarianSituationReports:

o UNHCR’sSituationReportsontheemergencyresponseinGreeceo UNHCR’sSyrianRefugeeArrivalsinGreece:PreliminaryQuestionnaire

• MSF’sReport,ObstacleCoursetoEurope:APolicy-MadeHumanitarianCrisisatEUBorders• WHO’sMentalHealthAtlas–Greeceprofile• Multi-AgencyGuidanceNoteforMentalHealthandPsychosocialSupportforRefugees,AsylumSeekers,

andMigrantsontheMoveinEurope• MHPSSAssessmentReports:

o IFRCPsychosocialCentreFieldVisitReport:PsychosocialSupportintheMigrationCrisis–AssessingthepsychosocialactivitiesandsupportprovidedbytheHellenicRedCrossandERUsintheirpsychosocialresponsetorefugees,asylumseekersandmigrantsonthemoveinEurope

o UNHCRMissionReport:MentalHealthTechnicalSupportMissiontoGreeceo WarTraumaFoundationReportforUNHCR–2015Report&Basic4W’sMHPSSGreeceo NeedsAssessmentforACTAllianceResponsetotheRefugeeCrisisinEurope–Greece,Macedonia

(FYROM),Serbia,andHungary• UNHCR,UNFPA,andWomen’sRefugeeCommissionInitialAssessmentReport:ProtectionRisksfor

WomenandGirlsintheEuropeanRefugeeandMigrantCrisis–GreeceandtheformerYugoslavRepublicofMacedonia

FieldVisitsandInterviewsConducted:Fieldvisitswereconductedtofirstreceptioncenters,transitsites,hostingsites,anddetentionsitesinLesvos,Samos,Leros,Kos,andAthens.MHPSSassessmentdatawerecollectedfromdiscussionswithkeyinformants(e.g.DirectorofBabeloutpatientcenter–NikosGionakis;SeniorMentalHealthOfficeroftheWorldHealthOrganization in Geneva – Peter Ventevogel), aswell as general discussionswith various representatives ofLNGOs, INGOs, the Red Cross/Red Crescent Movement, and the UN working on MHPSS in Greece, andmembersofthenewlystartedMHPSSTechnicalWorkingGroupinLesvos.3.BackgroundandContext

3.1RefugeeandMigrationCrisisThemassmigrationofrefugees,asylumseekers,andmigrantstoEuropehasbeenthelargestmovementofpeopleEuropehasseensinceWorldWarII.Themajorityofarrivalshavebeenfleeingwar,violence,humanrights abuses, and other forms of persecution in the Middle East and Central Asia, while others fromimpoverished South Asian and African countries are seeking better economic opportunities – all riskingdangeroustravelbyseaandbylandinattemptstofindrefugeandanewfutureinEurope.In2015, therewere856,723arrivalsbysea inGreece,with90%ofarrivalscoming fromtheworld’s top10refugee-producingcountries,mostlySyria,Afghanistan,andIraq.InJanuaryandFebruary2016alone,120,565havealreadyarrived,ofwhich44%areSyrian,29%areAfghani,17%areIraqi,4%Iranian,3%Pakistani,and3%othernationalities.Ofthesearrivals,63%wereadults(66.7%male;33.3%female)and37%werechildren.2Sofarthisyear,nearly150havedrownedorgonemissingintheseavoyagetoGreece;thefirstdeathoftheyearwasatwo-year-oldgirl.Despitethedangersofthisperilousandpotentiallydeadlyseacrossing,especiallyduringwintermonths,thenumberofpeoplearrivingattheshoresofGreececontinuesdaily.ItissignificanttohighlightthatinGreece,refugees,asylumseekers,andmigrantsaretransitingthroughtheislandstoAthensquitequickly,within24hoursformostrefugeesinLesvos,to3-7daysforothersinLesvosand all across other islands. Refugees have been moving onwards to the Former Yugoslav Republic ofMacedoniathroughCentralEuropetoWesternEurope,whileasylumseekersandmigrantshavebeenstayinginAthensforweeksormonthswhileawaitingnewsofopportunitiestomoveonwardsdependingondifferentpotentialborderopenings.Policiestowardsrefugees,asylumseekers,andmigrantsinEuropehavebeenchangingregularly,bothwithinGreece and in bordering countries and destination countries inWestern Europe. Of note in Greece,manyNorth Africans (primarily Moroccans) are being detained and either held at detention sites in Athens ordeportedtotheirhomecountries.Additionally,Greecewillsoonbetransitioningtoanewsetofproceduresfor refugee relocation:arrivalswill stay in centralized “hotspots” in the islands,movedmorequickly to thegreaterAthensarea,and refugeeswillbematchedwithacceptingcountries,withuncleardeterminationofproceduresforasylumseekersandmigrants.Furthermore,thepoliciesforarrivalstotheGreekshoreshavealready changed in Lesvos,with Frontex (EUborder patrol) and theHellenic CoastGuard collecting peoplefromtheboatsoncetheycrossintoGreek/EUwaters;withNATO’sarrivalforthemonitoringofseacrossingstoGreece,moreproceduralchangesmayoccur.Finally,thereisarecentandsignificantchangeinpolicyintheFormerYugoslavRepublicofMacedonia,wherebycrossing fromGreece isonlyallowed forSyrianand Iraqirefugees;Afghanisarenolongerpermittedtocross.Asaresult,moreandmorepeoplearestayingfor lengthierperiodsinAthens,andthereareplansbetweentheGreekgovernmentandUNHCRto identifyorbuildhousing foranadditional30,000 refugees,migrants,and asylum seekers in mainland Greece. Similarly, discussions amongst humanitarian actors for thecoordinationandimplementationoffutureprogramminghasbeenshiftingfromanemphasisontheislands,towardsAthens,wherethesepopulationswillbestayinglongerandwillbeinneedofaidandsupportservicesforgreaterperiodsoftime.

2http://data.unhcr.org/mediterranean/country.php?id=83

3.2MentalHealthPoliciesandStrategiesinGreeceGreece has an officially approved national mental health policy (2001), and there is a mental health plan(2010).Notably,mentalhealthexpendituresarecoveredbytheMinistryofHealth(4.43%ofthetotalbudget),althoughmentalhealthisnotspecificallymentionedinthenationalhealthpolicy.Keypoints inthenationalmental health policy include the necessity of developing a community intervention network, promotion ofcommunity-based mental health services, and transition of mental health service users back into theworkforce. The mental health plan highlights the need for a shift of services and resources from mentalhospitals to community-based mental health facilities. Furthermore, mental health legislation was passed(1999), and legalprovisionspertaining tomentalhealthare stipulated inother laws (e.g. regardingwelfareanddisability).3AccordingtotheWHOMentalHealthAtlasforGreece,theavailabilityofmentalhealthfacilitiesareasfollows:

Theavailabilityofmentalhealthprofessionals4isrepresentedbelow:

3http://www.who.int/mental_health/evidence/atlas/profiles/grc_mh_profile.pdf4http://www.who.int/mental_health/evidence/atlas/profiles-2014/grc.pdf?ua=1

4.AssessmentResultsThemagnitudeof the refugeeandmigrantcrisis– in termsof the sheernumberofarrivals, the rapidityoftheir transit throughthe islandsandmainlandGreece,andtheever-changingcontextofpolicychangesandbordercrossingclosures–hasposedasignificantchallengetothehumanitarianresponse,especiallyfortheprovision of mental health and psychosocial support services. People are in transit, and all humanitarianassistance has had to adapt accordingly.Most often, refugees, asylum seekers, andmigrants are urgentlytryingtocontinuetheirjourneytoAthens,withrefugeesmovingonwardstoWesternEurope;theygenerallydonotwanttodelaytheirtravelsforanyreason,astheywanttocontinuewiththegrouptheyaretravelingwith,fearthebordersmightcloseatanytime,anddonotwanttobeleftbehind.Thishasledtochallengesinproviding aid, especially for the provision ofmedical assistance andMHPSS services. Several organizationsreported cases where people would have significant medical conditions or emergencies, or be inoverwhelminggriefduetothe lossofa lovedoneatseawhohasnotbeenfoundorburied,andmadethedifficultdecisiontocontinuetheirjourney.Humanitarian assistance is being provided by a variety of local and international actors, including firstresponsebyGreekauthorities(e.g.coastguard,police),localandinternationalsearchandrescueteams,theUnitedNations(e.g.UNHCR),theHellenicRedCrosswithsupportfromvariousothernationalsocieties,localand international humanitarian NGOs, and volunteersworking in groups or independently (e.g. welcomingboatsandparticipatingindistributions;diversfacilitatingrescuesfromshipwrecksorpullingbodiesfromthesea).Greekhospitals,aswellasmedicalandmentalhealthclinics,havealsobeenprovidingfreecaretotheseinternationalpopulations,oftenthroughtheassistanceofinterpretersprovidedbyvariousNGOsandtheUN.AUNHCRgeneralmappingofWho’sDoingWhatWhere(3Ws)intheGreekislands5ispresentedbelow:

5http://data.unhcr.org/mediterranean/documents.php?page=1&view=grid&Country[]=83

AUNHCRmappingof3WsforAthenshasbeencompleted,asamatrix(butisnotyetavailableasagraphic).4.1MHPSSAssessmentsandCoordinationAssessments: Previous assessments on mental health and psychosocial support needs, services, andrecommendationswereconductedbyINGOs,asfollows:

1) InternationalFederationoftheRedCross’sPsychosocialCentreFieldVisitReport:PsychosocialSupportintheMigrationCrisis–AssessingthepsychosocialactivitiesandsupportprovidedbytheHellenicRedCrossandERUsintheirpsychosocialresponsetorefugees,asylumseekersandmigrantsonthemoveinEurope

2) UNHCRMissionReport:MentalHealthTechnicalSupportMissiontoGreece3) WarTraumaFoundation’sReportforUNHCR–2015Report&Basic4W’sMHPSSGreece4) Needs Assessment for ACT Alliance Response to the Refugee Crisis in Europe – Greece,Macedonia

(FYROM),SerbiaandHungary

Additionally,therewasasignificantneedsassessmentregardingtheprotectionofwomenandgirlsconductedbyUNHCR,UNFPA,andWomen’sRefugeeCommission,entitled, InitialAssessmentReport:ProtectionRisksforWomenandGirlsintheEuropeanRefugeeandMigrantCrisis–GreeceandtheformerYugoslavRepublicofMacedonia.One of themost notable gaps in Greece was the absence of a comprehensivemapping ofMHPSS needs,services,andactorsacrossthe islandsand inAthens.Asaresult, InternationalMedicalCorpscompletedaninitialrapidassessmentandmappingofMHPSSservicesandactorsacrossfourtargetislands(Lesvos,Samos,Leros,andKos)asapartofamulti-sectorneedsassessment,andlatercompletedasimilarmappingexerciseinAthens.Coordination:Anadditionalgap identifiedhasbeenthecoordinationofMHPSSactorsand initiativesacrosstheislandsaswellasinAthensandtherestofGreece.Tothiseffect,IMCtogetherwithUNHCRlaunchedanMHPSS TechnicalWorkingGroup in Lesvoson20 January, 2016,which IMC took the leadon chairingwithsupportfromanINGO,HumanityCrew;recently,thechairingwastransitionedtolonger-termactorsincludingHumanityCrew,IRC,andMdMGreece.There is no MHPSS Technical Working Group on other islands, although an informal ad-hoc MHPSScoordinationmeeting takes place periodically in Samos; there are no knownmechanisms in Leros or Kos.Furthermore, there are noMHPSS coordination mechanisms across the islands or in Athens. Significantly,therearealsonoclearreferralpathwaysbetweentheislandsandAthensorwithinAthens.Additionally,thereis a need for further training and capacity building for those working with refugees, asylum seekers, andmigrantsinAthensandelsewhereinmainlandGreece(e.g.Thessaloniki,Idomeni)regardingtheidentificationandsupportofthosewhomaybeinneedofMHPSSservices,andhowtofacilitatethosereferralprocesses.In an effort to facilitate communication, coordination, and collaboration amongMHPSS actors throughoutGreecetoenhancetheavailabilityandaccessibilityofMHPSSservicesacrosstheislandsandmainlandGreece,IMC created a group on mhpss.net for the Greece MHPSS response for refugees, asylum seekers, andmigrants.64.2MentalHealthCareAccessBasedonseveralconversationswithGreekandinternationalMHPSSprovidersinGreece,theunderstandingisthatrefugees,asylumseekers,andmigrantsareabletoaccesspublicinstitutionalorcommunity-basedmentalhealth and psychosocial support services in the islands as well as mainland Greece free of charge.Nevertheless, language is often a barrier and those accessing public mental health care often need to be

6http://mhpss.net/groups/current-mhpss-emergency-responses/mediterranean-migrant-crisis/greece-mhpss-response-for-refugees-asylum-seekers-migrants

accompaniedbyinterpreters.Additionally,onlyahandfulofnationalprovidershaveexperienceworkingwithinternational populations, and there is only one center with MHPSS services dedicated specifically forrefugees,asylumseekers,andmigrantsinAthensthatalsohasinterpretersavailable(BabelDayCentre)whichmaynotbeaknownresourceandmaybelogisticallychallengingtoaccessfromthevarioussiteswherethesepopulationsarestaying.In theGreek islandsaswellas inAthens,MHPSSservicesarequitecomprehensivelyprovidedbyboth localandinternationalNGOsinanumberofdifferentsettings,referencedbelowinsection4.4.4.3CurrentProblemsandStressorsAmongRefugees,Asylum-Seekers,andMigrantsThemajorityofpeoplearrivinghavenotonlyfledfromviolenceandpersecutionintheircountriesoforigin,butalsoenduredthestressoftherefugee/migrationrouteandencounterswithsmugglerstonegotiatetheirsea journey. Additionally,many experience frightening or traumatic journeys at sea, from shipwreckswithnear-deathexperiencesasmostdonotknowhowtoswimandmayhavebeensoldinauthenticlifejackets,towitnessingthedrowningofothersinfrontoftheireyes,includinglovedoneswithwhomtheyweretraveling.The process of arriving in Greece and being registered at reception centers and transferring to hosting ordetentionsitesmayexacerbatestressorsalready facedgiven familyseparationand lossduring the journey,andtheaffectedpopulationmaybeexposedtoexploitationandabuse.MHPSS-relatedstressorsamongstrefugee,asylum-seeking,andmigrantcommunitiesvarygreatly,intermsoftypeandintensity,dependingonanumberofimportantfactors:

• Whetherindividualsarefleeingfromwar,violence,and/orpersecution,displacement,andtheirpriorexposuretopsychologicaldistressand/orsocialstressors

• The migration experience from an individual’s home country to the Turkish coast, and potentialexposuretoexploitationorabuse(includinggender-basedviolence)

• ThejourneybyboatbetweenTurkeyandGreece,whichmaystartwithexploitationand/orabusebysmugglers, isgenerallyperceived tobe frightening,oftenatnightwithcoldandwetconditions,andwithpossibleshipwrecks,near-drowningexperiences,orwitnessingthedrowningofothers (possiblylovedones)aswellasexacerbationsofstressifthedeceasedarenotgivenaproperburial

• Uncertainty abouthow to addressbasic needs (e.g. food, clothing, shelter), especiallywith financialdifficulties

• Uncertaintyabouttheupcomingportionofthemigrationexperience(requiringtravelthroughtherestofGreeceandothercountriestotheirdestination)

• Separationfromfamilymembersand/orsocialsupportnetworks• Preexistingmentalillnessrequiringpsychotropicmedicationsfortreatment

Theaboveconsiderationsareoftenlinkedtothefollowingmentalhealthandpsychosocialresponses,whicharecommonreactionstostress: feelingoverwhelmed,confusion,distress,anger,sadness,concern,anxiety,fear,shock,numbness,and/ordetachment;difficultysleepingand/ornightmares.Somemayalsoexperiencegriefandbereavementwithtraumaticloss,ormoreserioussymptomsofmentalillness.Asaresult,MHPSS-relatedneedsforthesepopulationscanbecategorizedinthefollowingways:

• Family-andcommunity-levelsupport(e.g.throughcommunityspacesandservices)

• Basicpsychosocialsupportservices7• Accesstoinformationtoinformtheirplanningofnextstepsontheirjourney• Provisionofinformationandreferralstootheragenciesforaccesstobasicservices,suchasfood,non-

fooditems,designationofwhichsitetheywillstay• Access topsychotropicmedications (requiringcoordinationwithaGreekpsychiatrist forprescription

andpotentialfinancialassistancetopurchasethemedications)IdentifiedAt-RiskGroupsAccordingtomentalhealthpractitionersandhumanitarianactorsworkingontheislands,aswellasreflectionsonthesediscussionsduringfieldvisits,thefollowinggroupshavebeenidentifiedashigh-risk:

• Thosewho recently lost a loved one, especially due to a traumatic loss on the journey by boat toGreece

• Thoseseparatedfromtheirfamilies,especiallyunaccompaniedminors,whichhasbeenfoundtobeofhighprevalenceandconcern8

• Thosewhowererecentlyexposedtopsychologicaldistressduetowarand/orviolence• Thosewhosurvivedgender-basedviolenceintheircountryoforiginorintransit• Those with preexisting mental illness, including those without access to needed psychotropic

medications• Thosebelonging todisadvantaged groups (poor,marginalized, sick);women, the elderly; thosewho

areconsidered“thirdnationals”(e.g.asylumseekersandmigrants,oftensinglemales,whodonotfallintoaspecialprotectedgroup)

• Thosewithsubstanceabuseproblems(e.g.casesofopioidabuse)4.4MentalHealthandPsychosocialSupportServicesBasedonarapidassessmentofdifferentMHPSSservicesbeingprovidedacrossthe4islandsbyactorsfromLNGOs, INGOs, the Red Cross/Red Crescentmovement, and the UN, a brief summary is presented below,categorizedaccordingtotheIASCMHPSSInterventionPyramid.ThemainactorsprovidingMHPSSresponsearetheINGOsandlocalNGOS.ThehumanresourcescapacityforMHPSS consists of local MHPSS professionals, such as psychologists and social workers, as well asparaprofessionals facilitating community-based support. Others play important roles at the basic levels,offering support in the roles of providing information, orientation, and accompaniment todifferent servicepoints.Additionally,apsychiatristissometimesavailableateachisland’spublichospital.ThegeneralMHPSSresponseconsistsoftwomainstructures–themobileteamsforoutreachworkandfixedstations.Themobileteamsareeithermedicalmobileteamsorprotectionmobileteams.Themedicalmobileteamsareoftencomposedofamedicaldoctor,nurse,interpreterandasocialworker.ThefixedstationsareChildFriendlySpaces,WomanFriendlySpaces,andmedicalclinicswherepsychologistsandsocialworkersare 7Basicpsychosocialsupportmayoftenbeneededand/orbeneficial,butnotnecessarilysoughtaftergiventheshortdurationoftimeindividualsspendontheislands.Syrianrefugeesonlystayfor1-3days;otherrefugees3-4days;migrants7-10days.Accordingtoglobalbestpractices,psychologicalsupportshouldnotbestartedwithoutproperfollow-upmechanismsinplace.8Varioushumanitarianactorshavehighlightedthephenomenonofunaccompaniedminors.UNHCRhasbeenprocessingthecasesandreferringtosheltersrunbyLNGOs(e.g.PRAKSISandMETACTION),someofwhicharefull.

working. Furthermore, there are crisis intervention teams that are available at the shore when there areshipwrecksandthoseidentifiedasvulnerableandinneed/desireofpsychosocialsupportand/orcounseling.9Ofnote,onlya limitednumberof first responders, includinghumanitarianaidworkersandvolunteers,andveryfewGreekauthorities,havebeentrainedinPsychologicalFirstAid–andmanymayhavelefttheirrolesbynow,giventhehighturnoverrateamongaidworkersandvolunteersacrosstheislands.Furthermore,thereis no indication that any trainings have taken place regarding the identification and referral of thosewithpsychosocial distress ormental illness thatmay be in need ofMHPSS services, or on any existing referralpathways.Additionally, there do not appear to be any MHPSS Information, Education, and Communication (IEC)materials available (e.g. on common stress reactions, positive coping mechanisms, or symptoms ofpsychologicaldistress/mentalillness)fortherefugee,asylumseeker,andmigrantcommunity.InLesvos,Savethe Children is in the process of finalizing a brochure on children’s stress reactions and how parents canprovide support, and MSF is considering developing brochures on more common psychologicalsymptoms/disorders (e.g. depression, anxiety, posttraumatic stress); such brochures would be available inArabic,Farsi,andDari.Sofar,theintendeddistributionappearstobefocusedinLesvos;theredonotseemtobeplanstodistributeacrosstheislandsorinAthens/mainlandGreece.SnapshotofMHPSSServicesOfferedAcrossGreeceTheInter-AgencyStandingCommittee(IASC)(2007)GuidelinesonMentalhealthandPsychosocialSupportinEmergency Settings recommend levels ofmental health and psychosocial intervention based on a pyramidranging fromLevel1 - social considerations inbasic servicesandsecurityup toLevel4 - specializedmentalhealth services. A mapped outline of available services and supports in line with this pyramid is outlinedbelow,firstacrossfourislandsandtheninAthens.SnapshotAcross4TargetIslands(Lesvos,Samos,Leros,Kos)

Level1:SocialConsiderationsBasicsocialservices;

orientationinformation

Level2:Community&FamilySupportsChild-Friendly

Spaces;Women-FriendlySpaces

Level3:Focused(person-to-person)Non-specializedMHPSSServices

PsychosocialSupport;ReferralstoNeeded

Services

Level4:SpecializedServices

PsychologicalorPsychiatricInterventions

Lesvos

MoriaFirstReceptionSite

√√

(CFS;WFS)√ √

KaraTepeSite √√

(CFS;WFS)√ √

NorthernShore(Port&TransitSites)

√ √ √ √

9StandardOperatingProceduresforinterventionsarebeingformalizedinLesvosandinSamos;unknowninotherislands.

PIKPASite √ √ √ √

TransitUAMShelters

√ √ √

Samos

MalagariPort √√

(CFS)√

VathyPort √ √ √ KEPIDetentionSite

√√

(CFS)√

Leros

Port √ √

FirstReceptionSite

√ √ √

PIKPASite √ √ √

Kos

Park √ √

UNHCR-SupportedHotel

√ √(Familyactivities)

TransitUAMShelter

√ √ √

Level1:SocialConsiderationsinBasicServices&Security–Everysiteoffersaccesstoneededbasicservices,such as food, shelter, non-food items (clothing, shoes, blankets, hygiene kits, dignity kits), although theamount and selection of services vary by site. Amajority of these items are being provided by volunteerorganizations/initiativesaswellasbyNGOs,theRedCross/RedCrescentMovement,andUNHCR.Level2:Community&FamilySupports–ThereareChild-FriendlySpacesacrossmanysites(runbySavetheChildren/PRAKSIS,ARSIS,andHellenicRedCross);however, therearenocommunity-basedsupportservicesfor youth such as Youth-Friendly Spaces. Nevertheless, there are services offered specifically forunaccompaniedminorsinmanysites,includingtransitsheltersandcommunity/group-basedsupportservicesofferedforunaccompaniedminorsinLesvosandKos.ThereisalsoatransitshelterinLesvosforfamilieswithsmall children run by Caritas Hellas. There are Women-Friendly Spaces at both sites in Lesvos (run byActionAid),butnotonotherislands.Level 3: Focused (person-to-person) Non-specialized MHPSS Services – Nearly every single site offersindividual psychosocial support services, often using a clinical case management model by a psychologistand/or socialworkerusing interpreters, andgenerallyprovidedatornearmedical clinics.NGOs (e.g.MdMGreece,PRAKSIS(supportedbyIMCinMMUs),MedIn,METADRASI,HellenicRedCross,VillageofAllTogether,Babel)haveGreekpsychologistsandsocialworkers;INGOs(e.g.MSF,HumanityCrew,IsraAid,IRC,ILIAHTIDA)and IOM have expat psychologists and social workers.10MSF, Humanity Crew, IsraAid, and ActionAid have

10Level4and5servicesaremostlyprovidedbyGreekandexpatstaffviaArabicandFarsiinterpreters.MSFisonlyprovidingLevel4servicesonSamos,Leros,andKos;onLesvos,bothLevel4and5servicesarebeingoffered.IsraAidoffersLevel4&5servicesonLesvos.

Arabic-speaking psychologists. The exceptions to availability of Level 3 services include the UNHCR-rentedhotel for refugee families inKos,aswellas certainportand transit sites innorthernLesvoswherenosuchservices exist. Psychological First Aid (PFA) trainings for first responders have been conducted across theislandsandmainlandGreecebyWarTraumaFoundation/UNHCR,andinLesvosbytheHellenicRedCross.IMChasbeenconductingaseriesoftrainings,includingTrainingofTrainers,across4islands(Lesvos,Samos,Leros,Kos)andinAthens.Level4:SpecializedServices–PsychotherapyforindividualsandfamiliesisbeingprovidedbyMSFandIsraAidacross three sites in Lesvos.While nopsychiatric services are beingprovided at anyof the sites, there arereferralmechanisms and accompaniment services in place for individuals in need of psychiatric evaluationand/or prescription of psychotropic medications, facilitated by MHPSS staff of NGOs providing Level 3:Focused (person-to-person)non-specializedMHPSS.FromcaseexamplesprovidedbyMSFandMedIn staff,referrals toGreek psychiatrists at public hospitals have gone smoothlywhen cases are identified; howeverfromtheassessmentcompleted, it seemstheremaybechallenges to identifying thevastmajorityof thosewhomayhavepsychiatricorneurologicalproblemsandmaybe inneedof thesespecializedservices, likelyduetoacombinationofchallengesrangingfromtherapidtransitofthesepopulationsaswellasavailabilityoftrainedprofessionalstoidentifysuchcases.Anotherbarriernotedforaccesstocarewaslanguage,andNGO-hiredinterpretersaccompaniedclientsforthesereferrals.

SnapshotofMHPSSActors&ServicesOffered–IslandbyIsland

LESVOS

Mytilene Byairport Madamos Eftalou

Agency Activities MORIAregistration&hosting

site

KARATEPEsiteforrefugeefamilies

Othersites(e.g.

shelters)

PIKPAsitefor

vulnerablecases

MADAMADOStransitsite

APANEMAtransitsite

MSF-OCB Level3&4(individual,familysupport)

√ √ √

PRAKSIS Level2:CFS(withSave);transitshelter

√ √

Level2-3supportforUAMsatPRAKSIStransitshelter

√

HellenicRedCross(withsupportfromDanishRedCross)

PFATrainingandsupporttofirstresponders&volunteers;Non-specializedMHPSSinterventions(i.e.psychosocialsupportprograms);PFATrainings;StressManagementsessionsforHRCstaff

√ √ √

IsraAid Level3&4(individual,familysupport;arttherapy)

√ √ √

IRC Levels2&3&4forSGBVsurvivors,UAM,childreninseveredistressandotheridentifiedvulnerablecases

√ √ √ √

MdM Level3;evaluates&supportsallUAMs;workswithsurvivorsofshipwrecks

√ √

HumanityCrew

Level3forshipwrecksurvivorsatPIKPA(PlansforLeve4-psychiatrist);PFAonshore;Trainingsontrauma,NET,dramatherapy,culturalsensitivityinPSS

√ √

VillageofAllTogether

PIKPAshelterandLevels1-4supportforvulnerablepopulations,especiallyshipwrecksurvivors

√

SavetheChildren

Level2:CFS(withPRAKSIS);mother-babyareas;transitshelter(withPRAKSIS)

√ √

METADRASI

Level2-3supportforUAMsatMETADRASItransitshelter

√

CaritasHellas

SupportforrefugeefamilieswithchildrenatCaritastransitshelter(SilverBayHotel)includingprotection,legalinformation,basicpsychosocialsupport&child-friendlyarea

√

ActionAid Women-FriendlySpaces

√ √

ILIAHTIDA PSS&casemanagement

√

HealthPoint–OliveGrove

BasicPSSsupport(inprocessofimplementing)

√

Babel PeriodicvisitsforsupporttosurvivorsofshipwrecksandtoPIKPAstaff

√

SAMOS

Location

Agency Activities MALAGARIPORT

VATHYPORT

KEPIDETENTION

SITEMSF-France Non-specializedMHPSS

interventions(i.e.psychosocialsupportprograms)

√ √

PRAKSIS Non-specializedMHPSSinterventions(i.e.psychosocialsupportprograms)viaMMU(supportedbyIMC)

√

Child-FriendlySpace(withSavetheChildren)

√

MedIn Non-specializedMHPSSinterventions(i.e.psychosocialsupportprograms).EvaluationsofallnewlyregisteredpersonsatKEPI.Referrals.Activitiesforchildren.

√

HellenicRedCross

Child-FriendlySpaces;PFATraining&supporttofirstresponders;Non-specializedMHPSSinterventions(i.e.psychosocialsupportprograms)

√

LEROS

Location

Agency Activities SITE PORT PIKPA(firstreceptionsite)

MSF-OCB Non-specializedMHPSSinterventions(i.e.psychosocialsupportprograms)

√

PRAKSIS Non-specializedMHPSSinterventions(i.e.psychosocialsupportprograms)viaMMU(supportedbyIMC)

√ √

SavetheChildren/ARSIS

Non-specializedMHPSSinterventionsforunaccompaniedminors

√(CFS)

PIKPA Non-specializedMHPSSinterventionsforvulnerablepopulations

√

KOS

Location

Agency Activities ARCH/CALPARK HOTEL(supportedby

UNHCR)

UAMShelter

MSF-OCB Non-specializedMHPSSinterventions(i.e.psychosocialsupportprograms)

√

PRAKSIS Level2-creativearts-basedinitiatives(supportedbySave)

√

SavetheChildren

Level2-creativearts-basedinitiativesviaPRAKSIS

√

HellenicRedCross

PFATrainingandsupporttofirstresponders&volunteers;Non-specializedMHPSSinterventions(i.e.psychosocialsupportprograms)

√

MdM PSSactivitiesinpartnershipwithARSIS

MercyCorps Level2familyactivitiesathotel

√

SnapshotofMHPSSActors&ServicesOffered–Athens11

Level1:SocialConsiderationsBasicsocialservices;

orientationinformation

Level2:Community&FamilySupportsChild-Friendly

Spaces;Women-FriendlySpaces

Level3:Focused(person-to-person)Non-specializedMHPSSServices

PsychosocialSupport;ReferralstoNeeded

Services

Level4:SpecializedServices

PsychologicalorPsychiatricInterventions

Athens

ElaionasSite √ √ √

EllenikoSite √ √ √

UAMShelters √ √ √

PolyclinicsforRefugees,AsylumSeekers,&Migrants

√ √ √ √

Community-BasedMHPSSCenters

√ √ √ √

Agency Athens-BasedActivities

Babel CommunitycenterthatoffersavarietyofMHPSSservicesspecificallyformigrantsandrefugees,includinglinkstosocialservices,accompanimentforreferrals,provisionofbasicpsychosocialsupport/counseling,psychotherapy,andpsychiatricevaluations/interventions.Thecenteroffersindividual,family,group,andorganizationalcounseling,aswellaspublicawareness/sensitizationcampaignsandtrainings.JointprojectwithMSFandGreekRefugeeCouncilforaprogramforSurvivorsofTorture(ofwhichBabelprovidesMHPSSservices).Interpretersavailable.

MdM Polyclinicforvulnerableindividuals,includingrefugeesandmigrants.Onstaffisasocialworker,psychologists,psychiatrists;MMUsinElineas&Ellenikowithpsychosocialsupportservicestostartanyday;psychosocialsupportofferedonferries(psychologist&socialworker).Interpretersavailable.

PRAKSIS Polyclinicforvulnerableindividuals,includingrefugeesandmigrants,thatoffersbasicpsychosocialsupportfromcasemanagers;referralsmadetopsychologists;spaceforrecreationalactivitiesforchildren.Interpretersavailable.

11BasedonaveryrapidmappingofMHPSSactorsandserviceswhileassessingAthens;giventhelackofanMHPSScoordinationmechanismaswellaslimitedtimefortheassessment,theremaybegapsinthismapping.

Klimaka MHPSSviaoutpatientclinic(Levels2-4socialservices,psychological,&psychiatric);IOLAOSguesthousefor10refugees&asylumseekerswhohavepsychiatricproblems.Suicidepreventionhotline(1018).

GreekCouncilforRefugees

Psychosocialservices-socialworkersatrefugeereceptioncenterprovidecounseling&culturalorientation;psychologicalservices.GCR’sSocialUnitconsistsoftheReceptionUnit,theCentralSocialService,theOfficeforpromotiontoEmploymentandtheInterculturalCentreforthePromotionofRefugeeIntegration"Pyxis".

HellenicRedCross Psychosocialsupporttoshipwrecksurvivors;RestoringFamilyLinks;FamilyTracing&Reunification,includingpost-mortemreunificationofbodies&facilitationofburialprocess

METADRASI(MEDACTION)

PsychosocialsupportinsheltersforUAMs;socialservicesinElaionassite

ARSISAssociationfortheSocialSupportofYouth

Psychosocialsupportforvulnerableyouth;socialandrecreationalservicesandcounseling

SavetheChildren CFSatElleniko&atCaritasHotel

CaritasHellas PSSatshelters,includingUAMShelter

SoSVillage Recreational/psychosocialsupportforchildrenatElaionas

KETHEAMosaic Basicpsychosocialsupportforsubstanceabusers

KentroZois/CentreforLife

MHPSSforHIV/AIDSpopulation

DIKTIO/NetworkofSocialSupportforRefugees&Immigrants

Programthatoffersbasicsocialsupportsforrefugees&immigrants

IOM PsychosocialsupportatOpenCentreformigrantsregisteredforAssistedVoluntaryReturnandReintegration

MSF-France PossibleMHPSSinKorinthosDetentionCenter;TBD

5.SummaryandRecommendations5.1SummaryOverall, Greece has a well-structured system of MHPSS support, including national level mental healthpoliciesandguidelines,mentalhealthservicesandprofessionalsworkingtowardsincreasinglydecentralized&deinstitutionalizedbasedmodelsofmentalhealthcare,academicprograms forgeneraland specializedmentalhealthtraining,aswellassomelocalandinternationalpartnersformentalhealthcapacitybuildinginlinewithglobalstandards.Basedontheassessmentcompleted,theneeds includeastrengthenedMHPSScoordination and referral system, ongoing trainings in Psychological First Aid for first responders andhumanitarianworkers throughout the country, and capacity-building for the identification and referral ofthosewhomaybeinneedofpsychosocial,psychological,andpsychiatricservices.

5.2Recommendations

IASCMHPSSInterventionPyramid

5.2.1ImprovethecoordinationofmentalhealthandpsychosocialsupportservicesandactivitiesTheIASCMHPSSGuidelinesrecommendaunifiedMHPSScoordinationgrouptofacilitatethecommunicationandcoordinationbetweenactorsworkingonMHPSS,aswellas to linkactivitiesandcrosscutting initiativeswithothersectors(e.g.health,protection,nutrition).AnMHPSSTechnicalWorkingGroupwasestablishedinLesvosandshouldcontinueitseffortstoharmonizetheresponsewithinLesvosaswellastomainlandGreece.Itwouldbebeneficialforotherislandstoadaptaformalor informalcoordinationmechanismforMHPSSaswell.Furthermore,anMHPSScoordinationgroup, ideally throughthe launchofaTechnicalWorkingGroup,should be established in Athens, with links to MHPSS actors/coordination groups in the islands, to sharevaluableassessment reports, trainingmaterials, IECmaterials, to identifyandstrengthen referralpathways,andtoidentifyotherareasforcommunication,collaboration,andcoordination,e.g.forinformation-raisingoradvocacy initiatives. There should be a sharing of essential updates between MHPSS actors/coordinationgroupsandtheHealthandProtectionCoordinationGroups.Theseeffortscanalsobeenhancedthroughthesharingof informationviadedicatedgroupssuchas thenewlyestablished“GreeceMHPSSResponseto theRefugees/Migration Emergency Response” and the Europe – Mediterranean Migration Response onmhpss.net.12

12http://mhpss.net/groups/current-mhpss-emergency-responses/mediterranean-migrant-crisis/resources/

Global standards outlined in the Inter-AgencyStanding Committee (IASC) Guidelines onMental Health and Psychosocial Support inEmergency Settings (2007) includerecommendations on different levels ofmentalhealth and psychosocial intervention using apyramid approach, with basic needs and socialconsiderations at the foundation, andincreasingly advanced services to the top withspecializedmentalhealth services.Additionally,keyrecommendationshavebeenoutlinedintheMulti-AgencyGuidanceNote forMentalHealthand Psychosocial Support for Refugees, AsylumSeekers, andMigrants on theMove in Europe(2015). The following recommendations aremade in efforts to address the variousMHPSSgaps identified throughout Greece, includingways inwhich theavailability, accessibility, andcoordination of MHPSS services could bestrengthened and the capacity of MHPSS staffandothersupportstaffcouldbeenhanced.

5.2.2AdvocatefortheinclusionandexpansionofcomprehensiveMHPSSservicesThere should be ongoing advocacy for inclusion and expansion ofMHPSS services in both immediate andlonger-termprogrammingforthesepopulationsastheyarebeingdisplacedinGreeceforincreasingperiodsoftime. Recommendations include the following: 1) Support for awareness-raising campaigns on MHPSSconsiderations at the community level to help identify, refer, and support people withmental health andpsychosocialproblems,acrosstheislandsandinAthens;2)Promotecommunity-basedpsychosocialsupportinitiatives,suchasgroupandcommunity-orienteddiscussionsandIECmaterialsoncommonstressreactions,psychosocialwellbeing,andpositivecopingmechanisms;3)Provisionofbasic trainingandcapacity-buildingforcommunity-levelworkersinidentificationofpeoplewithmentalhealthproblemsinordertoprovidebasicpsychosocialsupportandreferralstohealth/mentalhealthfacilities;4)Ensurethatthemostvulnerableandinneed have access to MHPSS services, in collaboration with national and international MHPSS actors,coordinated through theMentalHealthandPsychosocial Supportworkinggroupsaswell as in thebroaderHealthandProtectioncoordinationgroups.5.2.3 Ensure there is continued provision of trainings in Psychological First Aid for first responders,humanitarianaidworkers,andgovernmentstaffworkingonthehumanitarianresponseacrossGreeceInconsiderationofthestressandemotionaldistressthatmanyrefugees,migrantshavefaced,thereshouldbeincreasedemphasisplacedonensuringthatfirstresponders,humanitarianaidworkers,andgovernmentstaffcomingintodirectcontactwiththesepopulationsaretrainedinPsychologicalFirstAid(PFA).AseriesofPFAtrainings, including Training of Trainers, have already been conducted or arranged by IMC as well asWarTraumaFoundation/UNHCRandtheHellenicRedCross;furthertrainingsshouldbeorganizedtoensurethatall target staff and volunteers are PFA-trained, especially considering the high turn-over rate of staff andvolunteersacrosstheislands.5.2.4PromotetheneedfortrainingsontheidentificationandreferralofthosewithpotentialMHPSSneeds,andexistingreferralpathwaysGiventhehighnumberofrefugees,asylumseekers,andmigrantswhohaveexperiencedsignificantstressandemotional distress, as well as those who may have preexisting mental illness, efforts should be made toorganizetrainingsontheidentificationandreferralofthosewithpsychosocialdistressormental illnessthatmaybeinneedofMHPSSservices,aswellasonexistingreferralpathways,sothatthoseinneedofsupportareprovidedwithinformationonwheretoaccesstheseservicesiftheyaredesired.

InternationalMedicalCorps1313LSt,NW,Suite220Washington,DC20005Phone:202.828.5155Web:https://internationalmedicalcorps.org/mentalhealth